King Saud university Nursing College Medical-Surgical department NUR 317

1. King Saud university Nursing College Medical-Surgical department NUR 317 Care for patients undergoing surgical intervention

2. Out line : 1- Phases of Perioperative Period a. Preoperative b. Intraoperative c. Post operative 2- Principles of Sterile Technique 3- Home Care 4- Medication

3. Phases of Perioperative Period • 1. Preoperative - begins when the decision for surgical intervention is made and ends with the transference of the patient to the operating room table • ROLE OF THE NURSE: • - Establishing a baseline assessment of the patient in clinical setting or at home • Carrying out a preoperative interview ( physical, emotional assessment, previous anesthetic history, allergies, genetic problems that may affect surgical outcomes) • - preadmission testing • providing preparatory education about recovery from anesthesia and postoperative care

4. I - PREOPERATIVE PERIOD ROLE OF THE NURSEON THE DAY OF SURGERY: - review patient teaching - Verify patient’s identity and the surgical site - confirm informed consent is confirmed - start an intravenous infusion - verify availability of safe transport and the presence of an accompanying responsible adult ( If the patient is going home the same day) - perform or update the preoperative patient assessment and address questions of the patient or family

5. I - PREOPERATIVE PERIOD Nursing process overview 1- ASSESSMENT A- General physical Assessment - Nutritional status - Respiratory status ( difficulty of breathing, bronchial Asthma, Blood gas analysis) - Cardiovascular Status - Hepatic and Renal Function - Endocrine Function (life threatening hazard: hypoglycemia, glucosuria) - Immunologic function (Allergy, Blood transfusion Reactions, Immunosuppressive medications - Effects of aging ( hydration status, modified lifestyle) - Prior drug therapy (history of drug use ( adrenal steroids, diuretics, phenothiazines, antidepressants, insulin, antibiotics ( “Mycin “ drugs)

6. I - PREOPERATIVE PERIOD B- Psychosocial Nursing Assessment - Preoperative Anxiety (fears of pain or death, fear of the unknown, fear of destruction of body image, fear of separation) Financial worries, Poor prognosis - Denial of anxiety C- Patient problems l Nursing Diagnosis - insufficient / inadequate information related to disease condition/ anesthetic agent - worry, depression and fear related to diagnosis and outcome of surgery - post operative pain and complication - risk factors related to previous lifestyle and history ( weight problems, smoking history, allergy

7. I - PREOPERATIVE PERIOD 2- PLANNING AND IMPLEMENTATION A- Preparation: - Approach the patient with an air of decision and interest in his well being - Determine exactly what procedures are to be performed - Explain what you are about to do B- General physical Status - replacement of deficits, obesity, addiction to narcotics, drugs or alcohol stop smoking 4-6 weeks before surgery, maintain adequate ventilation , antibiotics - avoid sudden changes in position, prolonged immobilization, hypotension, hypoxia and overloading of the body with fluids or blood - report sneezing , coughing, sniffling to the physician

8. I - PREOPERATIVE PERIOD • C- Preoperative Anxiety • - Have the patient express his anxiety. Listen to the patient • - Spiritual Therapy • - Recreation and diversion • D- Nutrition and Fluids • - Intravenous Access • - Light diet for dinner • - NPO post midnight • E- Intestinal Preparation • Warm cleansing enema • F- Preoperative Skin Preparation • - Warm, relaxing bath or shower prior to surgery, using betadine soap • - Skin at and around the operative site NOT be shaved (check hospital policy)

9. I - PREOPERATIVE PERIOD • 3- Operative Permit/ informed Consent • The nurse may ask the patient to sign the form and may witness the patient’s signature. • It is the physician’s responsibility to provide appropriate information. • Informed consent is necessary in the following circumstances: • • Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis • • Procedures requiring sedation and/or anesthesia • • A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient • • Procedures involving radiation

10. I - PREOPERATIVE PERIOD CRITERIA FOR VALID INFORMED CONSENT Voluntary Consent Valid consent must be freely given, without coercion. Incompetent Patient Legal definition: individual who is not autonomous and cannot give or withhold consent: * individuals who are MINOR * mentally retarded * mentally ill * comatose

11. I - PREOPERATIVE PERIOD CRITERIA FOR VALID INFORMED CONSENT Informed Subject Informed consent should be in writing. It should contain the following: • Explanation of procedure and its risks • Description of benefits and alternatives • An offer to answer questions about procedure • Instructions that the patient may withdraw consent • A statement informing the patient if the protocol differs from customary procedure Patient Able to Comprehend Information must be written and delivered in language understandable to the patient. Questions must be answered to facilitate comprehension if material is confusing.

12. 4- PREOPERATIVE PATIENT EDUCATION a- Deep Breathing and Coughing B- Turning and Active Body Movement - Turn patient side to side assuming Sim’s Lateral position - ROM Exercises (Extension and flexion of the knees and hip joints, Rotation of foot

13. I - PREOPERATIVE PERIOD C- Immediate Preoperative Preparation - Patient is brought to the OR 30-60 minutes before anesthesia is to be started - Patient in hospital gown, untied and open in the back - For long hair, Hair is plaited in two braids, hairpins removed, cover hair with disposable paper cap - Remove jewelries, dentures, prosthetic devices and labelled clearly with the patient’s name and stored in a safe place according to hospital policy - Have patient void, measure urine and note time and amount and record in the preoperative checklist - Administer preanesthetic medications to reduce patient’s anxiety or reduce secretions 45 to 75 minutes before anesthesia is begun

14. Phases of Perioperative Period 2- Intraoperative– begins when the patient is admitted or transferred to the Surgery department and ends when he is admitted to the recovery area ROLE OF THE NURSE: - Starting the IV and giving IV medications - Carrying out the full scope of physiologic monitoring throughout a surgical procedure - Providing for the patient safety

15. II - Intraoperative Period a- Circulating nurse :Registered nurse who coordinates and documents patient care in the operating room

16. II - Intraoperative Period B - Scrub nurse - Registered nurse , licensed practical nurse , or surgical technologist who scrubs and dons sterile surgical attire , prepares instruments and supplies , and hands instruments to the surgeon during the procedure - Assisting in positioning the patient on the operating table using basic principles of body mechanics

17. II - INTRAOPERATIVE PERIOD • a-Anesthesia – produces a state of narcosis, analgesia, relaxation and reflex loss • - General (liquid, gas) • Parts of the body (regional, spinal, local, topical) • b - Position in the Operating Room: • * Dorsal recumbent • * TrendelenburgPosition • * Lithotomy • * Sim’sLateral • B- Principles of Perioperative Asepsis • ( sterile to sterile, unsterile to unsterile)

18. Phases of Perioperative Period 3- Post operative- begins with the admission of the patient in the recovery room and ends with the follow up evaluation in the clinical setting or at home ROLE OF THE NURSE: - Assessing the post operative status of the patient in terms of anesthetic effect and the impact of surgery on body image or role function - Evaluating the family’s perception of the surgery - Communicating patient’s information about surgery to personnel in the Recovery or Surgical nursing unit

19. III - POSTOPERATIVE PERIOD • FOCUS OF CARE DURING IMMEDIATE POST OPERATIVE PERIOD : • a- maintain patient’s airway • * Monitor patient’s vital signs q15 min., movement, circulation, response • * Assess tubings, drainage bottles, • * Asses the effects of anesthetic agents • * Relief of pain, respiratory difficulties, • * Prevention of shock and other complications ( infection) • * Management of other post operative discomforts ( vomiting, abdominal distention,thirst, hiccups, constipation,fecal impaction, diarrhea ) • * Patients were released from PARR when the Aldrete and Kroulik) index reached a total of 10 points • * If score is less than 7, patient must remain in the recovery room

21. III - POSTOPERATIVE PERIOD • d- Wound Care • E - Leg Exercises • e- Home Care • - Pain management • - Wound care and dressing changes • - Monitoring for infection • - Activity restrictions • - Recommended sexual activity • - Ability to perform self care activities • Nutrition and elimination • Reference: Smeltzer and Bare . Brunner & Suddarth’s Medical Surgical Nursing 10th Ed